The physician and sportsmedicine

Exercise in Treating Hypertension

Tailoring Therapies for Active Patients

Jirayos Chintanadilok, MD
David T. Lowenthal, MD, PhD

Exercise and Sports Cardiology Series

Editor: Paul D. Thompson, MD

THE PHYSICIAN AND SPORTSMEDICINE - VOL 30 - NO. 3 - MARCH 2002

For CME accreditation information, instructions and learning objectives, click here.

In Brief: Even mild-to-moderate elevations in blood pressure dramatically increase the

risk of left ventricular hypertrophy, stroke, and renal disease. Although antihypertensive
drugs can reduce blood pressure, their side effects and cost have stimulated a search for
alternatives. Nonpharmocologic interventions can serve as definitive therapy for selected
patients and as adjunctive therapy for many hypertensive patients. Patients with
secondary hypertension should be treated directly and may not derive as much benefit
from exercise. Low-to-moderate intensity aerobic exercise can help mildly hypertensive
patients and reduce the drug dosage of those more severely affected. For active patients
who require medication, regimens can be tailored to minimize adverse drug effects.

Hypertension is defined as blood pressure equal to or greater than 140/90 mm Hg with

or without antihypertensive medication use, and approximately 50 million Americans are
hypertensive.1 Individuals who have blood pressure that is more than 160/95 mm Hg
have an annual incidence of coronary artery disease (CAD), congestive heart failure,
intermittent claudication, and stroke that is up to to three times higher than
normotensive persons.2 They also have an exercise capacity about 30% less.3

Regular moderate aerobic activity can safely lower blood pressure4-12 and reduce the risk
of future hypertension in children.13-15 Exercise recommendations are based on the sixth
National Report.4 The intensity can generally be increased without an extensive medical
evaluation as long as symptoms of overt cardiac, neurologic, and musculoskeletal
diseases are not provoked by walking. Physicians may encounter patients with secondary
hypertension, such as those with renal artery stenosis, coarctation of the aorta,
adrenocortical or benign tumors, or unexplained hypokalemia, and should treat them
directly; these patients may not benefit as much from exercise. Tailored exercise
prescriptions can lower blood pressure in hypertensive patients, including those on
medication.

Nonpharmacologic Blood Pressure Reduction

All current guidelines recommend exercise as an adjunctive nonpharmacologic

intervention for mild hypertension, and antihypertensive medications for more severe
disease. The data from the Hypertension Detection and Follow-up Program indicate that
pharmacologic management reduces mortality in hypertensive patients. 16 The study also
strongly supports assessing mildly hypertensive patients individually and prescribing
drugs according to composite risk factors rather than solely on blood pressure. Some
patients with mild hypertension have a low risk of developing cardiovascular diseases and
can safely be spared antihypertensive drugs. For others, medications may have no
benefit17 or increase mortality.18 Preventing coronary heart disease among hypertensive
patients requires a combination of nonpharmacologic treatments that seek to decrease
atherosclerosis. Lifestyle interventions include losing weight, exercising more, reducing
dietary salt, reducing stress, and lowering alcohol consumption. Currently, aerobic
exercise and diet-induced weight loss have emerged as the most effective and
physiologically desirable approaches.19 A large clinical trial20 has demonstrated that mild-
to-moderate exercise and weight loss can lower systolic and diastolic blood pressure in
both men and women, although another study21 showed that exercise and diet-induced
weight loss had no additive effect.

Many studies22-26 have validated exercise for treating high blood pressure. Exercise not
only reduces blood pressure, it also lowers levels of low-density lipoprotein cholesterol,
reduces insulin resistance and glucose intolerance, and often is associated with reduced
body weight.27,28

The Sixth Joint National Committee guidelines4 for initiating drug therapy should be
followed once low-risk patients have undergone 6 to 12 months of nonpharmacologic
approaches. Physicians should give a detailed exercise prescription and provide regular
encouragement and follow-up to improve patients' compliance and motivation.

How to Prescribe Exercise

Patient selection and evaluation. All patients with controlled hypertension should
participate in exercise training (table 1). Exercise can be used with other
nonpharmacologic interventions, and in uncomplicated mild-to-moderate hypertensive
patients without antihypertensive medications. Patients with cardiovascular complications
(eg, target-organ damage or diabetes) or who are elderly require antihypertensive
drugs.4 Patients with blood pressure greater than 180/105 mm Hg should add endurance
exercise training only after medication controls their blood pressure. The exercise may
reduce blood pressure further, decrease the dosage of antihypertensive agents required,
and attenuate the risk of premature mortality.

Initially, the pretraining assessment requires a focused clinical evaluation (figure 1). The
history should address significant CAD, syncope or near-syncope (due to hypertrophic
cardiomyopathy, valvular heart disease, or arrhythmias), premature CAD or sudden
death in family members, or other conditions that might limit exercise capability. The
physical examination should emphasize the cardiovascular and musculoskeletal systems.
A resting electrocardiogram (ECG) is recommended for all hypertensive patients, whether
or not they want to start an exercise program.
TABLE 1. Exercise Prescriptions for Selected Groups of Patients Who Have Borderline-to-Moderate-Hypertension

Program Element Adolescent Obese Diabetic Adult Onset Elderly

Patient selection and Prescribe Look for associated Exclude silent MI Prescribe adjuvant Give precautions for
evaluation antihypertensive diseases: diabetes, therapy for falls
medication to reduce mellitus, ischemic Look for associated postmenopausal
baseline resting pressure heart disease, diseases: lipid women (eg, Check for
peripheral vascular disorders, retinopathy, hormone musculoskeletal
Switch to an endurance disease peripheral neuropathy, replacement diseases:
sport; heavy-resistance peripheral vascular therapy) osteoarthritis,
sports are Emphasize weight loss disease, renal osteoporosis,
contraindicated as the first priority insufficiency, herniated disk,
depressed left fractures
Prescribe a walking ventricular function
program as tolerated Look for associated
to lose some weight Control blood glucose and underlying
before testing diseases, especially
Modify drugs and diet neurologic or
to avoid exercise- cardiovascular
induced hypoglycemia disorders

Exercise testing and GXT with Bruce protocol
monitoring to gauge magnitude of
BP response during
exercise and rate of
recovery
GXT with a modified
Naughton protocol
GXT with a modified For patients without GXT with a modified
Naughton protocol risk factors, begin Naughton protocol
with a walking
Rule out asymptomatic program without a
ischemic heart disease maximal GXT

Radionuclide imaging if For others, GXT with

needed a modified Naughton
protocol

Exercise type Aerobic activities: Aerobic, low-impact Aerobic, low-impact Aerobic activities: Aerobic, low-impact
jogging, biking, activities: walking until activities: walking, jogging; if more activities: walking,
swimming weight loss is 10%- biking, swimming than 40 yr old, low- biking, swimming,
15%, then biking, impact exercise: tai chi
Circuit weight training step-climbing, walking, swimming,
swimming, treadmill biking
walking

Frequency 6-7 days/wk 5 days/wk (minimum) 5 days/wk (minimum) 5 days/wk 2-5 days/wk
(minimum) (minimum)

Intensity Up to 85% of maximum
HRR or 85% of maximal
heart rates
Start at 50%-60%
maximum HRR and
lowly increase to 70%;
within 6 wk, work at
85% HRR or from
50%-90% of maximal
heart rate
Start at 50%-60% Start at 50%-60% Start at 50%-60%
maximum HRR and maximum HRR and maximum HRR and
slowly increase to slowly increase to slowly increase to
70%; within 6 wk, 70%; within 6 wk, 70%; within 6 wk,
work at 85% HRR or work at 85% HRR or work at 85% HRR or
from 50%-90% of from 50%-90% of from 50%-90% of
maximal heart rate maximal heart rate maximal heart rate

Duration 45-50 min/day 20-30 min/day of 20-30 min/day of 20-30 min/day of Duration depends on
continuous activity for continuous activity for continuous activity intensity of the
first 3 wk, then 30-45 first 3 wk, then 30-45 for first 3 wks, then activity: lower
min/day for next 4 to 6 min/day for next 4 to 6 30-45 min/day for intensity for longer
wk, and 60 min/day as wk, and 60 min/day as the next 4-6 wk, periods, can start
maintenance maintenance then 30-45 min/day with 20-30 min/day
for next 4-6 wk, and of continuous activity
60 min/day as for first 3 wk, then
maintenance 30-45 min/day for
next 4-6 wk, and 60
min/day as
maintenance

MI = myocardial infarction; GXT = graded exercise test; BP = blood pressure; HRR = heart resting rate

Reprinted with permission from Thompson PD (ed): Exercise and Sports Cardiology. New York City, McGraw-Hill, 2001, p 417.
Patients with renal damage. Some patients with end-stage renal disease can benefit
from exercise training. In patients with predialysis chronic renal failure, Boyce et al 29
found improved functional aerobic capacity, greater muscle strength, and reduced blood
pressure (up to 20 mm Hg) after 4 months of exercise. As noted for other patients,
cessation of exercise resulted in detraining effects; blood pressure increased within 2
months. Hemodialysis patients with chronic renal failure showed similar results, but the
effects were greater in individuals with essential hypertension. 30

Exercise substantially reduced the required doses of antihypertensive drugs.31,32 Patients

with unilateral renovascular disease and controlled blood pressure can exercise without
further damage to the kidneys. Jessup et al 33 have shown that healthy elderly persons
can endure 4 months of exercise training with no decrement in renal function.

Exercise Testing and Monitoring

The role of exercise testing is not settled. Most patients require only a good clinical
evaluation. Sudden cardiac death is the most worrisome potential complication of
exercise, but the absolute risk is very minimal (see "Cardiovascular Risks of Exercise:
Avoiding Sudden Death and Myocardial Infarction). CAD and hypertrophic
cardiomyopathy, the most common causes of sudden death in the old and young,
respectively, can be associated with hypertension and can be detected by careful history
taking, physical examination, resting ECG, and an echocardiogram.

The American College of Sports Medicine recommends that an exaggerated blood

pressure response to exercise should not be used as a screening test to identify those at
high risk of developing hypertension. However, exercise test information does provide
some indication of risk stratification for the patient with a blood pressure response above
the 85th percentile.34

Graded exercise stress tests (GXTs) can gauge the magnitude of blood pressure response
during exercise and rate of recovery, as well as the provocation of arrhythmias during
the test. Physicians often recommend GXTs for adults older than 40 who plan to begin an
exercise training program (see table 1).

Most patients with mild hypertension and no other cardiovascular disease risk factors can
start a walking exercise program without a maximal GXT, but patient health and age
determine the test required. Patients with moderate-to-severe hypertension who show
ECG evidence of left ventricular hypertrophy should have a GXT and probably myocardial
radioimaging.34 Diabetic hypertensive patients should be evaluated carefully with
exercise testing because they have a high incidence of silent myocardial infarction. A
treadmill GXT should use protocols that maintain a constant walking speed for accurate
blood pressure measurement during the exercise.35

Exercise to Meet Patient Needs

Endurance exercise is the preferred type for hypertensive patients. The blood pressure
response to aerobic exercise depends on the activity.

Aerobic exercise. Most studies have examined walking, running, or cycling. Walking
and running do not cause a sustained increase in blood pressure and perhaps represent
the most suitable endurance exercises for hypertensive patients. Some patients exhibit
higher blood pressure with swimming than with running at comparable heart rates but
have smaller cardiopulmonary effects. Moderate swimming (30- to 45-minute sessions, 3
days/wk) can lower systolic but not diastolic blood pressure at rest.36 Swimming can be
an alternative exercise for patients who are obese, have exercise-induced asthma, or
have orthopedic injuries.

Vigorous activities done with rhythmic high force, such as sprinting or rowing, are
unsuitable for hypertensive patients. Downhill skiing can elevate blood pressure, and
mountain sports may exaggerate an elevated blood pressure response from the cold and
decreased partial pressure of oxygen.37

Tai chi chuan. This 1,000-year-old martial art is a low-impact exercise that combines
slow, rhythmic movements with changes in direction, plane, and center of balance. It is
simple and well tolerated by sedentary older persons. In one trial, 37 a tai chi program
reduced patients' blood pressure to about that achieved by moderate-intensity aerobic
exercise, but it did not change maximal aerobic capacity and produced fewer changes in
other measures of physical activity. No large-scale, randomized, controlled clinical trial
has documented its cardiovascular effects.
Exercise intensity, frequency, and duration. No specific guidelines delineate exercise
intensity and frequency, but little evidence justifies high-intensity exercise (>70%
VO2max) for lowering blood pressure.25

Endurance exercise training at 40% to 70% VO2max may be as or more effective than
high-intensity exercise in lowering blood pressure in hypertensive subjects.38
Intervention studies and the World Hypertension League consensus statement 39 suggest
that patients exercise at 50% to 85% maximum oxygen uptake for 20 to 60 minutes, 3
to 5 days per week. Alternatively, exercise heart rate should be within 50% to 70% of its
predicted maximum (220 2 age in years). Lower-intensity activity requires longer
duration: Exercise at 60% to 70% of maximum work capacity, 45 minutes per session, 3
days per week for 1 month, has the same hypotensive effect as exercise at 47%
maximum work capacity, 60 minutes per session, 3 days per week, for 2.5 months. 39-42
Low-intensity (about 50% maximum oxygen consumption) exercise is also more
beneficial than higher-intensity exercise for addressing stress. Exercise must produce a
conditioning effect, usually three or four exercise sessions of 30 to 45 minutes each week
at 60% to 70% of maximal heart rate.

Exercise training programs longer than 10 weeks appear to reduce systolic blood
pressure by 1 to 2 mm Hg and diastolic blood pressure by 2 to 2.5 mm Hg more than
shorter-duration programs.24 Generally, no further blood pressure reduction occurs after
3 months of training, except in rare instances.42,43 The program should be at least 1 to 3
months to reach the stable stage, and training should be maintained indefinitely, because
the hypotensive effect persists only as long as regular endurance exercise is maintained.

Drug Therapy for Active Hypertensive Patients

There is no "best" medication for the active hypertensive patient. Physicians should tailor
medication to the patient's status.

Hypertension only. The active hypertensive patient of any age could take a thiazide
diuretic, 12.5 mg to 25 mg daily, and a potassium supplement. Diuretics are effective
and inexpensive. Thiazides are useful in hypertensive postmenopausal women with
osteoporosis because these drugs decrease urinary calcium loss. All of the other classes
of antihypertensive drugs are effective in controlling blood pressure and, although they
are expensive, can be used as monotherapy for this type of hypertensive patient.
Patients who need to take a beta-blocker can gradually train through the blunted
cardiovascular response to aerobic exercise. Beta-blockers are also effective and
inexpensive.

Hypertension with other diseases. Hypertensive patients who have other diseases
require more specific treatment. For example, those with CAD would benefit from either a
calcium-entry blocker or a beta-blocker; a diabetic patient would need an angiotensin-
converting enzyme (ACE) inhibitor; and a patient who coughs while on an ACE inhibitor
but has left ventricular hypertrophy should take an angiotensin-2-receptor blocker. Active
elderly hypertensive men with prostatism would obtain blood pressure control as well as
relief from outlet obstruction with a peripheral alpha-blocker (eg, terazosin, doxazosin
mesylate). If these drugs cause dizziness or orthostatic hypotension, the alpha-blocker
tamsulosin can be given with any other low-dosage antihypertensive drug.

Antihypertensive Therapy and Exercise Performance

Antihypertensive treatment for athletes and other physically active people seeks to
control blood pressure without compromising actual exercise performance (or
performance surrogates such as increases in heart rate, stroke index, and cardiac index).
No absolute contraindications exist for using any drug class in such patients, although
certain classes are preferred or better tolerated (see "Exercise and Antihypertensive
Medications in Patients with Dyslipidemias").

Diuretics. These drugs limit plasma volume expansion required for aerobic training. 44
Thiazides depress blood pressure during exercise by decreasing peripheral resistance and
plasma volume. Long-term thiazide use does not reduce cardiac output. The effects of
loop-blocking drugs, such as furosemide, on exercise have not been well studied, but
these drugs are used infrequently for controlling blood pressure because they have a
short duration.

Hypokalemia is the most worrisome, yet manageable, problem in active individuals

taking diuretics. In hypokalemic states, muscle blood flow decreases, and during exercise
skeletal muscle necrosis may occur, resulting in rhabdomyolysis and acute renal failure.
To ensure against potassium loss, patients taking diuretics should receive supplements.

Beta-blockers. Unlike ACE inhibitors and calcium channel blockers, beta-blockers blunt
exercise-mediated increases in heart rate and cardiac output and may reduce exercise
performance. This response is more profound with nonselective beta blockade (eg,
propranolol), and is greater with chronic than with acute dosing. 45,46 Nevertheless,
training intensity can be estimated using a scale of perceived exertion in patients taking
beta-blockers.47,48

Comparison of patients taking propranolol, metoprolol, or placebo showed that in graded

exercise tests, heart rate, systolic blood pressure, and VO2max were reduced at
maximum exertion, although no major changes were seen in the anaerobic threshold.48,49
These exercise effects were dose related. There was no difference between the placebo
group and patients taking 40 mg/day of propranolol, but those who took 160 mg/day or
320 mg/day significantly reduced their heart rate response and VO2max. Metoprolol
users had less blunting of the heart rate. Beta-blockers may cause exertional fatigue and
elevated serum potassium concentrations during exercise to levels greater than those
seen with exercise alone, but clinical consequences in exercise are remote.46

Patients who have chronic lung disease with bronchospasm should avoid all beta-
blockers. Exercise-induced asthma should be managed with cromolyn sodium, and
selective beta-blockers, if indicated, can be used cautiously.

Virtually all studies of the effects of beta-blockers on exercise and how exercise alters the
pharmacodynamics and drug kinetics have been done in relatively young people. 48 In one
study49 of healthy elderly volunteers who performed 4 months of dynamic exercise
training, researchers saw no changes in propranolol's kinetic or protein-binding
characteristics.

Vasodilators. Alpha-adrenergic blocking drugs. Prazosin, terazosin, and doxazosin do

not suppress cardiac output or exercise capacity44 and are excellent choices for athletes
and other active patients. Prazosin decreases mean arterial blood pressure and total
peripheral resistance at rest and with dynamic work. In contrast to hydralazine
hydrochloride, prazosin blunts any reflex increase in heart rate or pressor response
during isometric exercise.50

Calcium channel blockers. In normal, active persons, verapamil, diltiazem, and nifedipine
exert adequate control during exercise, although a mild blunting of the diastolic blood
pressure response to handgrip was observed with verapamil.51 In hypertensive patients,
verapamil and nifedipine reduce systolic and diastolic blood pressure during exercise,
perhaps by reducing systemic vascular resistance.52,53 There is no change in serum
potassium levels between patients taking verapamil or nifedipine and those taking a
placebo during isometric exercise.51

These medications are beneficial for patients who are not good candidates for beta-
blockers, including those with bronchospastic pulmonary disease or type 1 diabetes
mellitus, and those in whom beta-blockers induce fatigue or are contraindicated.

ACE inhibitors. These drugs reduce systolic and diastolic blood pressure during
exercise.47 A review54 of early studies with the angiotensin-2 partial antagonist, saralasin,
also showed the same effect. In the absence of diabetes mellitus of either type, ACE
inhibitors do not influence microalbuminuria observed with prolonged vigorous physical
activity. Elevated serum potassium levels from ACE inhibitors and exercise do not have
clinical consequences because the drug does not blunt catecholamine action, so
potassium can move intracellularly. This contrasts with beta-blockers, which block
catecholamine action to drive potassium back into the cell.

The overall responses to dynamic and static activities are not impaired with these drugs
or the angiotensin-2-receptor blockers, losartan and valsartan.55

Central alpha agonists. Methyldopa in mildly hypertensive patients may decrease the
blood pressure response but does not alter the heart rate response to exercise.56,57
Clonidine reduces both blood pressure and heart rate at rest and very slightly during
exercise and produces an acute vagally mediated decrease in cardiac output that does
not persist with chronic use.58,59 Transdermal clonidine patches were superior to oral
atenolol in improving aerobic conditioning in a group of relatively young, mildly
hypertensive patients.60

Neither clonidine nor methyldopa augment the changes in serum potassium, renin, and
aldosterone levels that are normally observed in healthy persons who exercise61 or in
patients who take beta-blockers.48

The Road Ahead

Physical activity in the control and prevention of hypertension among adults has so many
advantages that physicians should not hesitate to recommend exercise for management.
Aerobic exercise or endurance training at low-to-moderate intensity is the exercise of
choice, and emerging modes, such as circuit weight training and tai chi, are promising
but require further study.

Antihypertensive medications such as diuretics and beta-blockers can interfere with

exercise performance, but others, such as ACE inhibitors, alpha-adrenergic blockers, and
calcium channel blockers, do not and are well tolerated by active individuals. A
combination of nonpharmacologic interventions, such as exercise and weight loss, may
provide sufficient benefit to decrease cardiovascular risks independent of drug treatment.

References

1. The fifth report of the Joint National Committee on Detection, Evaluation, and
Treatment of High Blood Pressure (JNCV). Arch Intern Med 1993;153(2):154-183
2. Kannel WB, Doyle JT, Ostfeld AM, et al: Optimal resources for primary prevention
of atherosclerotic diseases: Atherosclerosis Study Group. Circulation
1984;70(1):155A-205A
3. Lim PO, MacFadyen RJ, Clarkson PB, et al: Impaired exercise tolerance in
hypertensive patients. Ann Intern Med 1996;124(1 pt 1):41-55
4. The sixth report of the Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure. Arch Intern Med
1997;157(21):2413-2446
5. Blair SN, Goodyear NN, Gibbons LW, et al: Physical fitness and incidence of
hypertension in healthy normotensive men and women. JAMA 1984;252(4):487-
490
6. Rocchini AP: Cardiovascular regulation in obesity-induced hypertension.
Hypertension 1992;19(1 suppl):I56-I60
7. Hubert HB, Feinleib M, McNamara PM, et al: Obesity as an independent risk factor
for cardiolvascular disease: a 26-year follow-up of participants in the Framingham
Heart Study. Circulation 1983;67(5):968-977
8. Blair SN, Kohl HW 3rd, Paffenbarger RS Jr, et al: Physical fitness and all-cause
mortality: a prospective study of healthy men and women. JAMA
1989;262(17):2395-2401
9. Paffenbarger RS Jr, Hyde RT, Wing AL, et al: Physical activity, all-cause mortality,
and longevity of college alumni. N Engl J Med 1986;314(10):605-613
10. Powell KE, Thompson PD, Caspersen CJ, et al: Physical activity and the incidence
of coronary heart disease. Annu Rev Public Health 8:253-287
11. Reaven PD, Barrett-Connor E, Edelstein S: Relation between leisure-time physical
activity and blood pressure in older women. Circulation 1991;83(2):559-565
12. Paffenbarger RS Jr, Wing AL, Hyde RT, et al: Physical activity and incidence of
hypertension in college alumni. Am J Epidemiol 1983;117(3):245-257
13. Hofman A, Walter HJ, Connelly PA, et al: Blood pressure and physical fitness in
children. Hypertension 1987;9(2):188-191
14. Hansen HS, Froberg K, Nielsen JR, et al: Physical fitness, physical activity, and
blood pressure in children. Ann Clin Res 1988;20(suppl 48):68-70
15. Sallis JF, Patterson TL, Buono MJ, et al: Relation of cardiovascular fitness and
physical activity to cardiovascular disease risk factors in children and adults. Am J
Epidemiol 1988;127(5):933-941
16. Five-year findings of the hypertension detection and follow-up program: 1.
reduction in mortality of persons with high blood pressure, including mild
hypertension. Hypertension Detection and Follow-up Program Cooperative Group.
JAMA 1979;242(23):2562-2571
17. Hoes AW, Grobbee DE, Lubsen J: Does drug treatment improve survival?
reconciling the trials in mild-to-moderate hypertension. J Hypertens
1995;13(7):805-811
18. Egger M, Smith GD: Risks and benefits of treating mild hypertension: a misleading
meta-analysis? J Hypertens 1995;13(7):813-815
19. Gordon NF, Scott CB, Wilkinson WJ, et al: Exercise and mild essential
hypertension: recommendations for adults. Sports Med 1990;10(6):390-404
20. The effects of nonpharmacologic interventions on blood pressure of persons with
high normal levels: results of the Trials of Hypertension Prevention, phase 1. The
Trials of Hypertension Prevention Collaborative Research Group. JAMA
1992;267(9):1213-1220
21. Gordon NF, Scott CB, Levine BD: Comparison of single versus multiple lifestyle
interventions: are the antihypertensive effects of exercise training and diet-
induced weight loss additive? Am J Cardiol 1997;79(6):763-767
22. Arroll B, Beaglehole R: Does physical activity lower blood pressure? a critical
review of the clinical trials. J Clin Epidemiol 1992;45(5):439-447
23. Kelley G, McClellan P: Antihypertensive effects of aerobic exercise: a brief meta-
analysis review of randomized controlled trials. Am J Hypertens 1994;7(2):115-
119
24. Hagberg JM, Brown MD: Does exercise training play a role in the treatment of
essential hypertension. J Cardiovasc Risk 1995;2(4):296-302
25. Halbert JA, Silagy CA, Finucane P, et al: The effectiveness of exercise training in
lowering blood pressure: a meta-analysis of randomised controlled trials of 4
weeks or longer. J Hum Hypertens 1997;11(10):641-649
26. Kelley G: Dynamic resistance exercise and resting blood pressure in adults: a
meta-analysis. J Appl Physiol 1997;82(5):1559-1565
27. Wood PD, Haskell WL, Blair SN, et al: Increased exercise level and plasma
lipoprotein concentrations: a one-year, randomized, controlled study in sedentary,
middle-aged men. Metabolism 1983;32(1):31-39
28. Ramsay LE, Yeo WW, Chadwick IG, et al: Non-pharmacological therapy of
hypertension. Br Med Bull 1994;50(2):494-508
29. Boyce ML, Robergs RA, Avasthi PS, et al: Exercise training by individuals with
predialysis renal failure: cardiorespiratory endurance, hypertension, and renal
function. Am J Kidney Dis 1997;30(2):180-192
30. Painter PL, Nelson-Worel JN, Hill MM, et al: Effects of exercise training during
hemodialysis. Nephron 1986;43(2):87-92
31. Hagberg JM, Golberg AP, Ehsani AA, et al: Exercise training improves
hypertension in hemodialysis patients. Am J Nephrol 1983;3(4):209-212
32. Clorius JH, Mandelbaum A, Hupp T, et al: Exercise activates renal dysfunction in
hypertension. Am J Hypertens 1996;9(7):653-661
33. Jessup JV, Lowenthal DT, Pollock ML, et al: The effects of endurance training on
ambulatory blood pressure in normotensive older adults. Geriatr Nephrol Urol
1998;8(2):103-109
34. American College of Sports Medicine: Guidelines for Exercise Testing and
Prescription, ed 4. Philadelphia, Lea & Febiger, 1991, pp 1-10
35. Schauer J, Hanson P: Usefulness of a branching treadmill protocol for evaluation
of cardiac functional capacity. Am J Cardiol 1987;60(16):1371-1377
36. Tanaka H, Bassett DR Jr, Howley ET, et al: Swimming training lowers the resting
blood pressure in individuals with hypertension. J Hypertens 1997;15(6):651-657
37. Palatini P: Exercise haemodynamics in the normotensive and the hypertensive
subject. Clin Sci (Lond) 1994;87(3):275-287
38. Young DR, Appel LJ, Jee S, et al: The effects of aerobic exercise and T'ai Chi on
blood pressure in older people: results of a randomized trial. J Am Geriatr Soc
1999;47(3):277-284
39. Physical exercise in the management of hypertension: a consensus statement by
the World Hypertension League. J Hypertens 1991;9(3):283-287
40. McMurray RG, Ainsworth BE, Harrell JS, et al: Is physical activity or aerobic power
more influential on reducing cardiovascular disease risk factors? Med Sci Sports
Exerc 1998;30(10):1521-1529
41. Bouchard C: Genetics of aerobic power and capacity, in Malina RM, Bouchard C
(eds): Sports and Human Genetics, Champaign, IL: Human Kinetics, 1985, pp 59-
81
42. Braith RW, Pollock ML, Lowenthal DT, et al: Moderate- and high-intensity exercise
lowers blood pressure in normotensive subjects 60 to 79 years of age. Am J
Cardiol 1994;73(15):1124-1128
43. de Virgilio C, Nelson RJ, Milliken J, et al: Ascending aortic dissection in weight
lifters with cystic medial degeneration. Ann Thorac Surg 1990;49(4):638-642
44. Nadel ER, Fortney SM, Wenger CB: Effect of hydration state of circulatory and
thermal regulations. J Appl Physiol 1980;49(4):715-721
45. Gullestad L, Hallen J, Medbo JI, et al: The effect of acute vs chronic treatment
with beta-adrenoceptor blockade on exercise performance, haemodynamic and
metabolic parameters in healthy men and women. Br J Clin Pharmacol
1996;41(1):57-67
46. Van Baak MA: Beta-adrenoceptor blockade and exercise: an update. Sports Med
1988;5(4):209-225
47. Eston R, Connolly D: The use of ratings of perceived exertion for exercise
prescription in patients receiving beta-blocker therapy. Sports Med
1996;21(3):176-190
48. Pollock M, Lowenthal DT, Foster C, et al: Acute and chronic responses to exercise
in patients treated with beta blockers. J Cardiopul Rehabil 1991;11(2):132-144
49. Panton LB, Guillen GJ, Williams L, et al: The lack of effect of aerobic exercise
training on propranolol pharmacokinetics in young and elderly adults. J Clin
Pharmacol 1995;35(9):885-894
50. Polonia J, Martins L, Bravo-Faria D, et al: Higher left ventricle mass in
normotensives with exaggerated blood pressure responses to exercise associated
with higher ambulatory blood pressure load and sympathetic activity. Eur Heart J
1992;13(suppl A):S30-S36
51. Fragola PV, Romitelli S, Moretti A, et al: Precursors of established hypertension in
borderline hypertensives: a two-year follow-up. Int J Cardiol 1993;39:113-119
52. Subramanian B, Bowles MJ, Davies AB, et al: Combined therapy with verapamil
and propranolol in chronic stable angina. Am J Cardiol 1982;49(1):125-132
53. Moskowitz RM, Piccini PA, Nacarelli GV, et al: Nifedipine therapy for stable angina
pectoris: preliminary results of effects on angina frequency and treadmill exercise
response. Am J Cardiol 1979;44(5):811-816
54. Fagard R, Amery A, Reybrouck T, et al: Effects of angiotension antagonism on
hemodynamics, renin, and catecholamines during exercise. J Appl Physiol
1977;43(3):440-444
55. Lang RM, Elkayam U, Yellen LG, et al: Comparative effects of losartan and
enalapril on exercise capacity and clinical status in patients with heart failure: the
Losartan Pilot Exercise Study Investigators. J Am Coll Cardiol 1997;30(4):983-991
56. Sannerstedt R, Varnauskas E, Werko L: Hemodynamic effects of methyldopa
(Aldomet) at rest and during exercise in patients with arterial hypertension. Acta
Med Scand 1962;171(1):75-82
57. Rosenthal L, Affrime MB, Lowenthal DT, et al: Biochemical and dynamic responses
to single and repeated doses of methyldopa and propranolol during dynamic
physical activity. Clin Pharmacol Ther 1982;32(6):701-710
58. Lund-Johansen P: Hemodynamic changes at rest and during exercise in long-term
clonidine therapy of essential hypertension. Acta Med Scand 1974;1-2(1):111-115
59. Lowenthal DT, Affrime MB, Rosenthal L, et al: Dynamic and biochemical responses
to single and repeated doses of clonidine during dynamic physical activity. Clin
Pharmacol Ther 1982;32(1):18-24
 60. Davies SF, Graif JL, Husebye DG, et al: Comparative effects of transdermal
clonidine and oral atenolol on acute exercise performance and response to aerobic
conditioning in subjects with hypertension. Arch Intern Med 1989;149(7):1551-
1556

Lowenthal DT, Affrime MB, Falkner B, et al: Potassium disposition and neuroendocrine
effects of propranolol, methyldopa and clonidine during dynamic exercise. Clin Exp
Hypertens A 1982;4(9-10):1895-1911